Provider Demographics
NPI:1255174470
Name:MPANJA, AGNES M (CWON)
Entity type:Individual
Prefix:
First Name:AGNES
Middle Name:M
Last Name:MPANJA
Suffix:
Gender:F
Credentials:CWON
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6664 BALLENGER RUN BLVD
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21703-7918
Mailing Address - Country:US
Mailing Address - Phone:240-305-7922
Mailing Address - Fax:
Practice Address - Street 1:6664 BALLENGER RUN BLVD
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21703-7918
Practice Address - Country:US
Practice Address - Phone:240-305-7922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-15
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR182828163WX1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WX1500XNursing Service ProvidersRegistered NurseOstomy Care